Muscle, joint & pain

The PRTEE: Tracking Tennis Elbow Over Time

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Tennis elbow is judged over months, not weeks — which makes memory an unreliable witness and a single snapshot nearly useless. This is what the PRTEE's three subscales cover, why a rising score means a worsening elbow, what a landmark trial revealed about judging this condition too early, and what the form cannot decide on its own.

Last updated: July 2026

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What is the PRTEE?

The PRTEE is the Patient-Rated Tennis Elbow Evaluation: a questionnaire completed by the patient, covering pain in the elbow and the tasks that pain gets in the way of, producing a single total score. It is built to be filled in more than once, so that a total from today can be set against a total from two months ago.

Its name has a history, and the history explains some confusion you may run into. The instrument first appeared in 1999, published by Overend, Wuori-Fearn, Kramer and MacDermid under the earlier title Patient-Rated Forearm Evaluation Questionnaire, and was renamed afterwards. The standard validation under its current name arrived in 2007 from Rompe, Overend and MacDermid — the last of whom originated the measure 1. If you find both acronyms in the literature, they are the same lineage.

That 2007 study is the one everything rests on. It evaluated the PRTEE in 78 tennis players with chronic, unilateral, MRI-confirmed lateral elbow tendinopathy, measuring them at baseline and again at twelve weeks, and comparing the form against a visual analogue scale, the DASH, the Roles and Maudsley score, and the Upper Extremity Function Scale 1.

What the questionnaire asks about

The PRTEE is built in three parts, and the validation reports how internally consistent each one is — a measure of whether the items within a section behave as though they are asking about the same thing. The pain subscale came out at 0.94, the specific activities subscale at 0.93, and the usual activities subscale at 0.85 1. Those are strong figures, and the split is the point: pain and function are recorded separately rather than blended into one impression.

The scoring itself comes from the PRTEE User Manual that MacDermid published in 2010, not from the validation paper. It sets out fifteen items and a total out of 100, assembled from a pain half scored out of 50 and a function half scored out of 50 — and the direction catches people out.

On the PRTEE, higher is worse. A total of 0 is an elbow giving no trouble at all, and 100 is the worst the form can record.

This runs against the instinct built by scores where a big number is an achievement. If you are tracking your own totals, or reading them in a letter, the elbow is improving when the number is falling.

Why the PRTEE registered change better than the alternatives

Because it was designed for one condition, and in the 2007 study that narrowness paid. Responsiveness — the ability to detect real change when it happens — is the property that matters most in a form you intend to repeat, and the PRTEE produced a standardized response mean of 2.1, against 1.5 to 1.7 for the measures it was compared with 1. On that basis the authors concluded it was suitable as the standard primary outcome measure in tennis elbow research 1.

A standardized response mean is the size of the change divided by how much that change varies between people. It asks, in effect, how clearly a real improvement rings out above the noise. A higher figure means the instrument is less likely to miss something that genuinely happened.

The form also behaved as it should against the outside world: its subscales and total correlated well with the visual analogue scale and with the DASH 1. That matters, because an instrument that correlates with nothing may simply be measuring nothing.

So a general arm questionnaire and a single pain rating both work — they just work less sharply on this particular elbow. When the question is whether one condition at one joint is changing, a form written for that condition hears it first.

Why measuring across months matters in tennis elbow

Because this is a condition where an early verdict and a late verdict can disagree completely, and the evidence for that is unusually direct. In a randomized trial of people with unilateral lateral epicondylalgia, corticosteroid injection produced worse outcomes at one year, and higher recurrence, than a placebo injection; physiotherapy gave no significant added benefit at the one-year mark 2.

That finding is worth sitting with, because of what it implies about measurement. Recurrence is not a state — it is a pattern across time. No single reading can contain it. An outcome captured once and early cannot distinguish an elbow that has settled from an elbow that is between episodes, and the difference between those two only becomes visible if somebody keeps asking.

A treatment can look one way at twelve weeks and another way at fifty-two, and only repeated measurement shows the second answer 2.

This is the honest case for the form. Not that a questionnaire heals anything — but that tennis elbow healing time is counted in months, memory for pain is poor and heavily coloured by how things feel today, and a total recorded in March is the only reliable witness to how March actually was. Whether an injection or a course of therapy is right for you is a conversation with a clinician who knows your elbow, and that conversation goes better on a record than a recollection.

How much change on the PRTEE counts as real?

The validation paper does not answer this, and it is important not to read one into it. Responsiveness there is expressed only as a standardized response mean — the group-level statistic above. The study derives no minimal clinically important difference and no minimal detectable change 1. There is no threshold in it that tells an individual how many points constitute a genuine improvement.

Those figures do exist elsewhere. Work by Poltawski and Watson published in 2011 is the usual reference for change thresholds on this instrument, and a number quoted to you belongs to that literature rather than to the validation study.

The practical version is simple enough. A large fall in your total across a couple of months is meaningful in a way that a two-point wobble between one week and the next is not, because every questionnaire carries some measurement error and small movements live inside it. If a clinician cites a specific number of points as the target, it is fair to ask where the figure comes from and which patients it was derived in — the answer will not be the 2007 study.

The PRTEE, the DASH, and the condition-specific idea

These two forms embody opposite strategies, which is precisely why the PRTEE was tested against the DASH rather than beside it. The DASH is regional: developed by the Upper Extremity Collaborative Group in 1996 as a self-reported measure of symptoms and physical function spanning upper-extremity musculoskeletal disorders as a class 3, it treats the arm, shoulder and hand as one working unit and asks nothing about any joint in particular.

That breadth is a genuine strength. It lets one form follow a person whose problem is not confined to one place, and it lets results be compared across quite different upper-limb conditions.

The cost showed up in the tennis elbow sample: the narrow instrument out-registered the broad one in the population it was built for 1. That is the trade condition-specific measures make — less reach, more resolution.

The same idea has been applied joint by joint across musculoskeletal medicine. The koos questionnaire does it for the knee, with five subscales covering pain, symptoms, daily living, sport and recreation, and knee-related quality of life 4. The womac index and the hoos questionnaire sit in the same family. None of their totals converts into any other's, and none of them would notice an elbow.

What the PRTEE cannot do

It cannot tell you what is wrong with your elbow. The form assumes a diagnosis and measures its consequences — it starts after the question of what this is has already been answered by someone who examined you, and it has no mechanism for answering it itself.

The boundaries of its evidence are worth knowing plainly, because they are narrower than the form's use:

  • The validation sample was specific. 78 tennis players, with chronic, unilateral, MRI-confirmed lateral elbow tendinopathy 1. Most people with tennis elbow are not tennis players, have not had an MRI, and are not twelve weeks into a research protocol. That does not make the form useless outside those conditions — it does mean the psychometrics were established inside them.
  • It is a lateral elbow instrument. Pain on the inside of the elbow is a different problem, and whether what you have is tennis elbow or golfer's elbow decides whether this form is the right one at all. The evidence covers lateral elbow tendinopathy 1.
  • It sets no severity bands. There is no score that makes a case severe, and no cutoff in the validation that sorts elbows into categories.
  • It does not choose your treatment. A number does not decide between waiting, therapy, an injection or anything else. It records where the elbow is, so that whatever is chosen can be judged afterwards on something better than an impression.

Read that way, lateral epicondylitis becomes slightly less maddening to live with. A form exists because gradual, uneven change is exactly the kind people cannot perceive in themselves.

Common questions

Bad. The PRTEE runs in the direction people least expect: the total is out of 100, and higher means worse. A score of 0 describes an elbow causing no pain and no difficulty, while 100 is the worst the form can record. If you are tracking totals over time, improvement looks like the number going down.

It is built in three sections — a pain subscale, a specific activities subscale, and a usual activities subscale — so that pain and function are recorded separately rather than merged into one impression. The user manual sets it out as fifteen items totalling 100 points, split evenly between a pain half worth 50 and a function half worth 50.

That depends on what is being tracked and is worth agreeing with your clinician, but the instrument's logic is that a single reading has little value. The validation measured people at baseline and again at twelve weeks. Tennis elbow is judged over months, so intervals of several weeks give change room to appear above the form's own measurement noise.

The validation paper sets no threshold — it reports responsiveness as a group statistic and derives no minimal important difference or minimal detectable change. Change thresholds for the PRTEE come from separate later work, notably by Poltawski and Watson in 2011. If a figure is quoted to you, it comes from that literature rather than from the original study.

Its evidence does not extend there. The instrument was validated in people with lateral elbow tendinopathy — pain on the outside of the elbow — and pain on the inside is a different condition. Using a form outside the population it was tested in asks it for accuracy that nobody has established, even when the questions still seem to fit.

No. It assumes the diagnosis has already been made and measures what that condition is doing to you over time. In the validation study the diagnosis was confirmed by MRI before anyone filled in a form. A questionnaire records the consequences of a problem, and it has no way of identifying which problem it is.

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Elbow symptoms that need to be looked at, whatever the score says

  • —An elbow that is hot, swollen and severely painful with fever or chills, or any spreading redness — possible joint or skin infection, which needs same-day assessment
  • —Inability to straighten or bend the elbow after a fall or direct blow, visible deformity, or a sudden pop followed by weakness and bruising in the upper arm
  • —Numbness, pins and needles or weakness spreading into the hand or fingers, or a hand that is losing grip strength or dropping things
  • —Elbow pain that wakes you consistently at night, or that continues to worsen over months despite treatment rather than following the usual slow settling

A hot, swollen, acutely painful elbow with fever needs urgent medical assessment rather than a wait-and-see approach, as does an elbow that cannot be moved after an injury. If the arm becomes cold, pale or numb below the elbow, go to the emergency room.

This article explains an outcome measure and how it is interpreted. It is general education, not medical advice, and it cannot assess your elbow. A questionnaire score is not a diagnosis and does not replace evaluation by a clinician who can examine you and knows your history.

References

  1. 1.Rompe JD, Overend TJ, MacDermid JC (2007). Validation of the Patient-rated Tennis Elbow Evaluation Questionnaire. J Hand Ther. doi:10.1197/j.jht.2006.10.003 ✓The canonical validation of the PRTEE under its current name, co-authored by the instrument's originator: its evaluation in 78 tennis players with chronic, unilateral, MRI-confirmed lateral elbow tendinopathy at baseline and 12 weeks against the VAS, DASH, Roles and Maudsley score and Upper Extremity Function Scale; its reliability and internal consistency (pain subscale 0.94, specific activities 0.93, usual activities 0.85); its construct validity via good correlations between PRTEE subscales/total and the VAS and DASH; and its responsiveness, with a standardized response mean of 2.1 exceeding the comparator measures (SRM 1.5-1.7), supporting the authors' conclusion that it is suitable as the standard primary outcome measure in tennis elbow research. Also supports the absence of any MCID, MDC or severity cutoff in this paper. The 15-item structure, 0-100 total (pain 0-50 + function 0-50) and higher-is-worse direction are attributed in prose to the PRTEE User Manual (MacDermid, 2010), and the PRFEQ origin and rename to the 1999 Overend et al. paper — not to this source.
  2. 2.Coombes BK, Bisset L, Brooks P, Khan A, Vicenzino B (2013). Effect of Corticosteroid Injection, Physiotherapy, or Both on Clinical Outcomes in Patients With Unilateral Lateral Epicondylalgia: A Randomized Controlled Trial. JAMA. PMID 23385272 ✓That in unilateral lateral epicondylalgia, corticosteroid injection produced worse 1-year outcomes and higher recurrence than placebo injection, and that physiotherapy gave no significant added benefit at 1 year — used here to show why outcomes in tennis elbow must be measured across months rather than judged from a single early reading.
  3. 3.Hudak PL, Amadio PC, Bombardier C (Upper Extremity Collaborative Group) (1996). Development of an upper extremity outcome measure: the DASH (disabilities of the arm, shoulder, and hand). American Journal of Industrial Medicine. doi:10.1002/(SICI)1097-0274(199606)29:6<602::AID-AJIM4>3.0.CO;2-LThe development of the DASH as a validated self-reported measure of symptoms and physical function across upper-extremity musculoskeletal disorders — the regional approach contrasted here with the PRTEE's condition-specific one.
  4. 4.Roos EM, Roos HP, Lohmander LS, Ekdahl C, Beynnon BD (1998). Knee Injury and Osteoarthritis Outcome Score (KOOS)—Development of a Self-Administered Outcome Measure. Journal of Orthopaedic & Sports Physical Therapy. doi:10.2519/jospt.1998.28.2.88The KOOS as a validated self-administered patient-reported outcome for knee injury and osteoarthritis with five subscales (pain, symptoms, activities of daily living, sport and recreation, and knee-related quality of life) — cited as an example of the condition-specific instrument family.

4 sources, numbered by first appearance. General health information, not medical advice. AI-assisted editorial content — citations link their sources. Editorial policy

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